Using the UN Process Indicators of Emergency Obstetric Services. Questions and Answers

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1 AMDD Workbook Using the UN Process Indicators of Emergency Obstetric Services Questions and Answers Contributors: Anne Paxton Senior Program Officer Monitoring and Evaluation, AMDD Deborah Maine Program Director, AMDD Nadia Hijab Consultant, AMDD

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3 The Averting Maternal Death & Disability (AMDD) Program has produced this Workbook as a resource for planners and managers working to increase women s access to emergency obstetric services. UN Guidelines available at: This publication is supported by the Bill & Melinda Gates Foundation. May 2003 AMDD Heilbrunn Department of Population & Family Health Mailman School of Public Health Columbia University 60 Haven Ave., B-3 New York, NY

4 Preface The most important work we can do together to reduce death and disability in women due to complications in pregnancy and childbirth is to provide them with services that can save their lives and health. The workbook you are about to read contains information we hope will be of assistance as you document the efforts you are making to provide women with quality emergency obstetric services that are accessible to them wherever they live. The Guidelines for Monitoring the Availability and Use of Obstetric Services, issued by UNICEF, WHO and UNFPA in 1997, clearly describe why the information the UN Process Indicators contain is important, and how to collect and interpret the data. Nonetheless, questions are asked by people using the UN Process Indicators, many of whom have no prior experience using clinical data from hospital registers or in monitoring projects. This AMDD Workbook addresses some frequently asked questions, in an attempt to make the collection and interpretation of these data as accessible as possible to clinicians and facility managers in hospitals and health clinics, as well as to public health program managers. We hope you will be able to use the UN Process Indicators to monitor trends over time in your emergency obstetric facilities, and make the important decisions which must be made based upon what your data are telling you. The overall pattern of the data, and the decisions these data lead you to, are what is most important, not the precision of any one indicator. This workbook is produced on behalf of the Averting Maternal Death and Disability Program (AMDD). This is a revised version based on feedback we received from users as to what is most useful and what could be made clearer. Please give any additional feedback you might have to Dr. Anne Paxton at We would like to acknowledge the helpful review and comments of the following colleagues: Patricia Bailey, Barbara Kwast, Samantha Lobis, Dileep Makalavar, Sourou Gbangbade, and Kavita Bali. This workbook is a companion piece to the Guidelines for Monitoring the Availability and Use of Obstetric Services, originally developed by Columbia and UNICEF staff in 1991, with input from WHO. AMDD wishes to acknowledge the significant and on-going collaboration with UNICEF in the design and implementation of the UN Process Indicators. 1

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6 Frequently Asked Questions 1. Why were the UN Process Indicators developed? 2. What are the 6 UN Process Indicators? 3. How do we define the major direct obstetric complications? 4. What are Signal Functions, how are they measured, and why do we use them? 5. What if a facility performs almost all of the Signal Functions? 6. Which registers should we use to gather data? 7. How should we record complications in the facility registers? 8. How are data abstracted from the registers? 9. How are the UN Process Indicators calculated? 10. How do we deal with indirect causes of maternal death? 11. How do we collect data on complications of abortion? 12. How should referrals be handled? 13. What if women come from outside the catchment area? 14. Why use a series of indicators? 15. How are the UN Process Indicators useful at the facility level? 16. How is the case-fatality rate interpreted? 17. What other tools are available for analyzing quality of services? 2

7 1. WHY WERE THE UN PROCESS INDICATORS DEVELOPED? The majority of maternal deaths are due to direct obstetric causes such as postpartum hemorrhage, sepsis and complications of abortion. Indirect obstetric complications illnesses that are aggravated by the pregnancy such as anemia, malaria, tuberculosis, HIV/AIDS and various chronic conditions are increasing in parts of the world and accounting for an increasing proportion of maternal deaths. There is now an international consensus that making pregnancy and delivery safer includes ensuring that women who experience obstetric complications receive the medical care they need on time. Emergency services are needed to handle potentially life-threatening, direct obstetric complications that affect an estimated 15% of women during pregnancy, at delivery, or in the postpartum period 1. Accordingly, more governments are putting emergency obstetric care at the center of their maternal health programs, recognizing its importance to preventing death and disability in women. Naturally, planners and program managers want to know that their efforts to improve the quality and coverage of emergency obstetric services are making a difference for women who experience life-threatening complications. Tools to do so were developed by Columbia University and UNICEF in 1991, in the form of Guidelines for Monitoring the Availability and Use of Obstetric Services. These Guidelines were issued by UNICEF, WHO and UNFPA in The Guidelines introduced a set of six process indicators to monitor obstetric services. Process indicators measure activities that lead up to the desired goal in this case, the goal is reduction of maternal deaths. Examples of process indicators in other fields include percent of children immunized and percent of couples using modern family planning methods. The UN Process Indicators are based on the understanding that, to prevent maternal deaths, certain types of obstetric services must be available and used. The UN Process Indicators will tell you whether these services are available to women in sufficient quantity, and whether women who most need them those who experience a life-threatening obstetric emergency are, in fact, using them. And the UN Process Indicators will tell you a little about the quality of care, although other tools are needed to investigate quality in more depth. The indicators can be used both for needs assessments carried out for the purpose of program design, as well as for quantitatively monitoring progress in program implementation. Together, the six indicators give an indication as to whether women s lives are being saved as a result of the programs put in place 2. 1 Research has demonstrated that even in developed countries, about 15% of pregnant women will experience complications. See the Guidelines for more information. 2 Until the UN Process Indicators were developed, maternal mortality rates and ratios were the only way a country could tell if its women were dying in unacceptably high numbers from pregnancy-related complications. While the rates and ratios provide a snapshot of the severity of the problem, they are not as useful for the purposes of program design and monitoring. Accurate mortality surveys are labor- and time-intensive, expensive, and do not highlight the issues that health managers need to design and 4

8 2. WHAT ARE THE 6 UN PROCESS INDICATORS? The six UN Process Indicators are: 1. Amount of emergency obstetric care (EmOC) 3 services available 2. Geographical distribution of EmOC facilities 3. Proportion of all births in EmOC facilities 4. Met need for EmOC services 5. Cesarean sections as a percentage of all births in the population 6. Case fatality rate. Each indicator has standards for acceptable levels against which actual data can be compared. The UN Process Indicators and recommended levels are set out in Table 1, which is adapted from the Guidelines. Table 1: The Six UN Process Indicators and Recommended Levels UN Process Indicator Definition Recommended level 1. Amount of EmOC services available Number of facilities that provide EmOC Minimum: 1 Comprehensive EmOC facility for every 500,000 people 2. Geographical distribution of EmOC facilities 3. Proportion of all births in EmOC facilities 4. Met need for EmOC services 5. Cesarean sections as a percentage of all births Facilities providing EmOC well-distributed at subnational level 4 Proportion of all births in the population that take place in EmOC facilities Proportion of women with obstetric complications treated in EmOC facilities Cesarean deliveries as a proportion of all births in the population 6. Case fatality rate Proportion of women with obstetric complications admitted to a facility who die Minimum: 4 Basic EmOC facilities per 500,000 people Minimum: 100% of subnational areas have the minimum acceptable numbers of basic and comprehensive EmOC facilities Minimum: 15% At least 100% [Estimated as 15% of expected births. See Q9.] Minimum 5% Maximum 15% Maximum 1% monitor programs. Indeed, it is recommended that such surveys only be conducted every 10 years to show meaningful difference, whereas managers need to be able to track results over a period of months. 3 Note that in the Guidelines, instead of EmOC, the term EOC or essential obstetric care is used. 4 The geographical distribution is most clearly seen by plotting the EmOC facilities on a map. 5

9 Indicators 1 and 2 deal with coverage or availability, answering the question: Do enough EmOC services exist to serve the population? Indicator 3 deals with utilization, answering the question: Are the EmOC services being used by pregnant women? Indicators 4 and 5 also deal with utilization, but focuses on the question of complications: Are the EmOC services being used by women who really need them, i.e. women experiencing obstetric complications? And Indicator 6 tells us something about the quality of service, by answering the question of whether the facilities are saving women s lives. If a public health planner or facility manager knows that enough coverage of the population exists, women who experience obstetric complications are reaching the services that can save them from death and disability, and the facilities are functioning well enough to save lives, then he or she can be confident that many maternal deaths in the country are being averted. 3. HOW DO WE DEFINE THE MAJOR DIRECT OBSTETRIC COMPLICATIONS? The WHO definition of a maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes. There are seven direct obstetric causes of maternal death, all of which can be successfully treated without loss of life in the great majority of cases with adequate obstetric services. The Guidelines define these direct complications as: hemorrhage (antepartum or postpartum), prolonged/obstructed labor, postpartum sepsis, complications of abortion, pre-eclampsia/eclampsia, ectopic pregnancy, and ruptured uterus, and they account for about 85% of direct obstetric deaths. These complications occur suddenly, often without warning. Unless they are treated promptly, they become emergencies 5. Many countries will have national definitions for obstetric complications. The country s national standards can be harmonized with international definitions. Definitions for each of the direct obstetric complications have been developed by FIGO (the International Federation of Gynecology and Obstetrics) for the Save the Mothers Projects. Definitions can also be found in the WHO/UNFPA/UNICEF/World Bank manual 5 See also Safe Motherhood Programs: Options and Issues, which reviews much of the relevant literature; as well as Reducing Maternal Deaths: Selecting Priorities, Tracking Progress, UNFPA and Columbia University, produced by the UN Staff college at Turin,

10 Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors (WHO/RHR/00.7, 2000). Table 2 presents the major, direct obstetric complication in the left-hand column, and definitions derived from WHO and the FIGO Save the Mothers Project in the right-hand column. Table 2: Direct Obstetric Complications and Working Definitions Direct Obstetric Complication Definitions derived from WHO 6 and International Federation of Gynecology and Obstetrics Save the Mothers Projects Hemorrhage Antepartum Any bleeding before labor and during labor: placenta previa, abruptio placenta. Postpartum Bleeding that requires treatment (provision of intravenous fluids and/or blood transfusion); Retained placenta; Severe bleeding from lacerations (vaginal or cervical) Prolonged / Obstructed labour This is dystocia (abnormal labor) and will include: prolonged, established, first stage of labor (>12 hours) prolonged second stage of labor (>1 hour) CPD (cephalo-pelvic disproportion), transverse lie, brow/face presentation. If a women with a previous caesarian section has had a failed trial of scar 7, and again she requires a C-section, then the complication is CPD. If a woman has a C-section for fetal distress, she is registered as a C-section case, but has no maternal complication. 6 WHO/UNFPA/UNICEF/World Bank. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. Integrated Management for Pregnancy and Childbirth (MCPC). World Health Organization, Geneva, Switzerland, 2000, WHO/RHR/ From prior cesarean section. 7

11 Direct Obstetric Complication Postpartum sepsis Definitions derived from WHO and International Federation of Gynecology and Obstetrics Save the Mothers Projects A woman has a fever (temperature 38 degrees Centigrade or more) occurring more than 24 hours after delivery (with at least two readings because labor alone can cause some fever). Other signs and symptoms that can be present: lower abdominal pain, purulent, offensive vaginal discharge (lochia), tender uterus. (Rule out malaria) Complications of abortion Hemorrhage due to abortion, which requires resuscitation with IV fluids and/or blood transfusion. Sepsis due to abortion (this includes perforation and pelvic abscess) Note: abortion may be spontaneous or induced. Severe Pre-eclampsia Eclampsia Ectopic Pregnancy Ruptured Uterus Diastolic blood pressure >110 mmhg and proteinuria >3+ after 20 weeks gestation. Various signs and symptoms: headache, hyperflexia, blurred vision, oliguria, epigastric pain, pulmonary oedema. Convulsions. Diastolic blood pressure 90mmHG or more after 20 weeks gestation. Proteinuria 2+ or more. Various signs and symptoms: coma and other signs and symptoms of severe pre-eclampsia. Internal bleeding from a pregnancy outside the uterus. Lower abdominal pain and shock possible from internal bleeding. History of pregnancy. Uterine rupture with a history of prolonged/obstructed labor when uterine contractions suddenly stopped. Painful abdomen. Patient may be in shock from internal and/or vaginal bleeding. For practical purposes, you can think of a complication as an event of sufficient severity that staff must respond with a life-saving procedure or referral to another facility. To continue with the example of hemorrhage, if you needed to resuscitate the woman with intravenous fluids or a blood transfusion and/or perform a manual removal of placenta in order to save a woman's life, clearly that was an obstetric complication (and you should record it as such in your register.) If a woman arrives at the hospital with a high fever following an abortion and you treat with antibiotics, such a case should be considered a complication of abortion. Your procedure probably saved her from serious illness or death. If staff in a facility cannot recognize a condition that requires an emergency action, quality of care will be undermined. There are several excellent clinical guidelines 8

12 available that discuss signs and symptoms of various maternal conditions and the appropriate actions to take. Two such texts are: WHO/UNFPA/UNICEF/World Bank. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. Integrated Management for Pregnancy and Childbirth (MCPC). World Health Organization, Geneva, Switzerland, WHO/RHR/00.7 Enkin et al. A Guide to Effective Care in Pregnancy and Childbirth. Oxford University Press Some questions have come to our attention regarding specific obstetric experiences and whether they are considered direct obstetric complications as per these UN Process Indicators. For example, if labor is augmented with oxytocin and ends in a normal delivery, it is ONLY considered a complication if the oxytocin was given because the labor was prolonged or obstructed as per the definition above. The concern is that some doctors augment labor even when it is not yet a prolonged labor. This is why use of a partograph is so important to determine whether or not a woman is progressing in labor. An episiotomy, by itself, does not qualify as an assisted delivery. Another question concerns vaginal or cervical tears that are sutured immediately without much bleeding. These tears, if they do not result in loss of blood so that they fall into the category of postpartum hemorrhage, are not considered direct obstetric complications. It is very important for each team using the UN Process Indicators to state explicitly what complications they are including and how they are defining them, especially as these nuances emerge in practice. Some project managers and clinicians may be confident in their definition of a given obstetric complication, but be concerned that the complication may not be accurately measured, and thereby recorded, in a facility. Estimating blood loss to determine whether a woman is experiencing a hemorrhage may be difficult under any conditions, let alone in an emergency. We acknowledge this dilemma, but encourage everyone involved in collecting data for monitoring progress in provision of EmOC services to always keep in mind the purpose of our work, which is to treat women appropriately in order to save their lives. If these obstetric complications are the main direct obstetric cause of maternal death, you may ask, is there a list of key life-saving procedures? The answer is yes, and they are called "Signal Functions". 9

13 4. WHAT ARE SIGNAL FUNCTIONS, HOW ARE THEY MEASURED, AND WHY DO WE USE THEM? The Guidelines define a set of activities, called "Signal Functions" that should be available in a facility for emergency care of women with pregnancy-related complications. However, it is not an exhaustive list of the important emergency obstetric activities. These Signal Functions must be performed by a facility for it to be recognized as an Emergency Obstetric Care (EmOC) facility. There are eight Signal Functions, of which six can be performed at the level of a good health center. A facility performing all six is known as a Basic EmOC facility. Two additional functions are often available only at a hospital; a facility performing all eight functions qualifies as a Comprehensive EmOC facility. The Basic EmOC Signal Functions are: administer parenteral (intravenous or by injection) antibiotics, administer parenteral oxytocic drugs, administer parenteral anticonvulsants, perform manual removal of placenta, perform removal of retained products, and perform assisted vaginal delivery (vacuum extraction, forceps delivery.) 8 The functions performed at a Basic EmOC facility can save many women s lives. Even when the patient needs to be referred from a Basic EmOC facility to a Comprehensive one, the functions performed at the Basic EmOC facility may stabilize the woman so that she does not die on the way or arrive in a near-fatal condition at the Comprehensive EmOC facility. One of the signal functions "perform removal of retained products" requires a bit of explanation. This signal function is aimed at provision of emergency care for an incomplete abortion (spontaneous or induced) because retained products of conception lead to life-threatening complications of abortion sepsis and/or to hemorrhage. (Retained placental fragments is a post-birth complication that requires different management and refers more to the signal function "perform manual removal of placenta.") The manual Managing Complications in Pregnancy and Childbirth (MCPC) suggests that when bleeding is light to moderate in an incomplete abortion, "fingers or ring (or sponge) forceps may be used to remove products of conception protruding through the cervix." However, in an incomplete abortion with heavy bleeding, the recommended procedure is vacuum aspiration to remove retained products of 8 An episiotomy, by itself, does not qualify as an assisted delivery. In addition, augmentation of delivery with oxytocin, by itself, does not qualify as an assisted delivery. 10

14 conception (either manually, referred to as MVA 9, or electrically, referred to as EVA.) In many countries, we have found, vacuum aspiration is not taught or used frequently, and necessary equipment may not be available. Curettage may then be used, but is a less desirable technique due to the greater risk of complication. The Comprehensive EmOC functions are all six Basic Signal Functions plus: perform surgery (Cesarean section) perform blood transfusion. It should be noted that to perform surgery, anesthesia is required. During a needs assessment, and periodically over time, facilities are reviewed for the performance of these Signal Functions. Designation of a facility as an emergency obstetric care facility (Basic or Comprehensive) depends on these functions not only being available, but actually being performed at least once in a three month period. The UN Guidelines state very clearly that it is not the theoretical performance of these Signal Functions that matter but actual performance. The performance of the Signal Functions can be determined through a review of records, through observation, or through interview of staff. Many things can impede the performance of these Signal Functions interruption in supplies, equipment disrepair, staff absenteeism due to transfer, holiday, trainings or meetings, etc. It is important to note that patient volume will also have an impact on EmOC status of a facility. If so few women seek care at the facility that performance of the Signal Functions has not been necessary, the facility can not be considered an EmOC facility. Clearly, both technical and managerial factors play a part in a facility performing emergency obstetric services on a routine basis. In a needs assessment, it may be found that one or more Signal Functions have not been performed in facilities in the last three months. A program planner who undertakes an assessment of the functioning of facilities should look for patterns that might point to underlying policy issues that affect service delivery. For example, there might be policies limiting the ability of facilities to perform blood transfusion, or that place limits on what procedures nurses and midwives can perform. These policy issues could be addressed through advocacy that compares practices with other countries. Likewise, there may be managerial issues pertaining to drug supply, maintenance of equipment, or staffing that could be identified through analysis of patterns of Signal Functions in facilities. In some situations a facility that provides all EmOC Signal Functions at one point in time may not be performing these same functions six months or a year later. There are many possible reasons for a facility to lose its EmOC status. A key member of the 9 For more information on manual vacuum aspiration (MVA), please contact Ipas: 300 Market St., Suite 200, Chapel Hill, NC 27516, USA, tel: , fax: , 11

15 EmOC team (anesthesiologist, Oby/Gyn) may be away for an extended leave or may be transferred without an immediate replacement, and thus, no cesarean deliveries are performed. A crucial piece of equipment may be damaged, or the operating theatre may be closed for renovations. During routine supervision, project managers and external supervisors can check that a facility is still performing the Signal Functions, and if not, bring the identified management or policy problems to the attention of facility management and/or government counterparts. The periodicity of review of the Signal Functions performed at facilities will vary from place to place, depending on resources and the opinion of decision-makers on the utility of this activity. AMDD recommends that facilities be reassessed yearly, where possible. If an annual review of Signal Functions can be performed at all potential EmOC facilities in an area, it may be discovered that EmOC services are available in more facilities than were expected. Success in improving services in some facilities may inspire replication in neighboring facilities. In Table 3 below the seven direct obstetric complications that make up a complicated case as per the Guidelines are matched with one or several Signal Functions that might need to be performed to save the woman's life. Please! Do not look at this table as a clinical management guide. We have matched the complications with the Signal Functions only as a way to help you think about how you will record complications for the UN Process Indicators. Table 3: Obstetric Complications Matched to the Signal Functions Major Obstetric Complications Hemorrhage Signal Functions Antepartum: perform blood transfusion perform surgery (cesarean section for placenta previa, abruptio placenta) Postpartum: administer parenteral oxytocic drugs perform blood transfusion perform manual removal of placenta perform removal of retained products Prolonged / obstructed labor perform assisted vaginal delivery perform surgery (cesarean section) administer parenteral oxytocic drugs Postpartum sepsis administer parenteral (intravenous or by injection) antibiotics perform removal of retained products perform surgery for pelvic abcess 12

16 Major Obstetric Complications Signal Functions Complications of abortion For hemorrhage: perform blood transfusion perform removal of retained products For sepsis: administer parenteral antibiotics perform removal of retained products Pre-eclampsia / eclampsia administer parenteral anticonvulsants perform surgery (cesarean section) Ectopic pregnancy perform surgery perform blood transfusion Ruptured uterus perform surgery perform blood transfusion administer parenteral antibiotics 5. WHAT IF A FACILITY PERFORMS ALMOST ALL OF THE SIGNAL FUNCTIONS? In many countries, particularly in Latin America, assisted vaginal delivery is rarely performed as a matter of policy. Women who might benefit from this intervention are delivered by C-section. Techniques of assisted vaginal delivery eg. vacuum extraction or forceps delivery are no longer taught in many schools of medicine, nursing and midwifery in these countries. So, if it is found that all Signal Functions are performed in a facility except assisted vaginal delivery, can the facility be considered an EmOC facility? We answer this question with a qualified yes. If a strict interpretation of the definition of an EmOC facility were used, some countries would not have a single facility qualify, and this would misrepresent the real situation of emergency care for women. Therefore, if a facility performs all the Signal Functions to qualify as a basic emergency obstetric facility except this one, we might call it Basic EmOC minus one (with a footnote saying which one is missing). Similarly, for a facility that performs all the functions of a comprehensive emergency obstetric facility except assisted vaginal delivery, we might call it Comprehensive EmOC minus one. There are many advantages of assisted vaginal delivery over C-section. An experienced midwife or nurse can perform an assisted, vaginal delivery in a basic emergency obstetric facility. Anesthesia is not required as with a C-section, and the potential risks (due to bleeding, infection, complications from the anesthesia) to the woman are fewer. By pointing out that an important Signal Function is missing by labeling a facility "EmOC minus one", we are highlighting that an important service, recommended in the Guidelines, is not available to women, and that policy on that subject needs to be revisited. 13

17 6. WHICH REGISTERS SHOULD BE USED TO GATHER DATA? The data for the UN Process Indicators are not collected in a research setting, but rather from facility registers and records, filled in by staff during both routine care and emergencies. To calculate the UN Process Indicators, the data need to be collected routinely in facilities. Virtually all health facilities record some kind of routine data in the form of registers and patient records. The quality of these data varies greatly, as do the types and numbers of registers and records used. The facility data required to formulate the UN Process Indicators include: number of deliveries in the facility, number of complicated cases, number of cesarean sections, and number of maternal deaths. Data on deliveries, C-sections and maternal deaths are commonly collected in health facilities, although usually not in the same register. Data on births are easily found on an admissions register, a labor and delivery register, or a maternity ward register. The operating theater register is usually the most complete record of data on C-sections. Data on maternal deaths may be found on a maternity / obstetric register, a discharge register (if used by the facility) or, perhaps, a separate register for all deaths in the facility. Gathering data on complications is less straightforward. Facility registers generally do not have a place to record obstetric complications, in which case a column for this information must be added. Hospital and project managers should resist the urge to create a new, separate register devoted to obstetric complications or other data for the UN Process Indicators. It is more useful to the facility to improve and revitalize existing registers than to create more administrative work for busy clinicians. Women with complications may be treated in the labor or maternity ward (for example, women with prolonged labor) while women with postpartum sepsis may be seen and treated in a gynecology, general or female ward. Complications from abortions or ectopic pregnancies may also be recorded in a female or general ward. Complications can sometimes be located in operating theatre registers, for example, cases of ruptured uterus or ectopic pregnancy, or cases of hemorrhage requiring blood transfusions. We recommend that you carry out an analysis of the flow of obstetric patients through a facility that shows where and how data are recorded, especially on obstetric complications and maternal deaths, before choosing which registers to use for collecting data for the UN Process Indicators. The most complete and accurate registers should be used before those that might contain only some of this information. 14

18 When performing the needs assessment for the first time, it may be necessary to look at other sources of information. Patient records such as the "bed head ticket" (the patient chart placed at the foot of a hospital bed) or individual patient files can be useful especially for complications. These same records may also be useful to validate the data in the registers while checking for completeness and accuracy. Patient records are too cumbersome to be used for routine data recording, however, and should not be used as a substitute for patient registers. 7. HOW SHOULD WE RECORD COMPLICATIONS IN THE FACILITY REGISTERS? When recording obstetric complications at your facility, here are some things to keep in mind: Make sure that there is a place in the appropriate register to record complications (including registers in female or gynecology wards where women with complications of abortions, ectopic pregnancies, or puerperal sepsis may be seen). When calculating Met Need, only one obstetric complication per woman should be counted. Data on obstetric complications treated more accurately should be called data on women who experienced at least one major obstetric complication. Make sure that the registers are being filled out consistently and completely, and have them routinely reviewed by a supervisor. To ensure consistency, it may be useful to post a list of the seven major obstetric complications with their definitions in the area where the registers are filled-in or in the register itself. This is important because if women with complications are being treated at your facility, but the information is not put in the registers, met need will appear lower than it actually is (and the case fatality rate will appear higher than it actually is, as discussed later). Remember: obstetric complications are unpredictable and can occur in the facility unexpectedly. For example, postpartum hemorrhage can occur without warning and is not the fault of the attendant. The complication should be registered in both the case notes and the register. Encourage staff not to underreport due to feelings of guilt or misplaced culpability. Remind them that a high number of complications treated shows that women are coming to the facility and receiving care. 8. HOW ARE DATA ABSTRACTED FROM THE REGISTERS? Many facilities have a system in place to compile their obstetric data on a monthly, quarterly or semi-annual basis. Reports may be used internally, or may be required by health authorities or donor agencies. In the projects conducted by AMDD's partners, a semi-annual reporting form is used, compiling data each six months on deliveries in the 15

19 facilities, major obstetric complications treated, C-sections performed, and maternal deaths. When reviewing the registers that will be used to complete the summary form, a number of data collection problems may be identified, especially when a new process is being undertaken in a facility, such as filling in data on obstetric complications for the first time. In an AMDD-sponsored tool developed with EngenderHealth entitled Emergency Obstetric Care: Toolbook for Improving the Quality of Services there is an entire chapter devoted to conducting a review of registers and records with an eye to improving the quality and completeness of data collection. (To access this document and for information on how to order copies, please go to the AMDD website One concern in compiling data from a number of registers, such as data on obstetric complications, is that women will be identified as a complication on more than one register. It is important that staff at each facility understands the flow of obstetric patients and why the data are being collected so that large numbers of cases of obstetric complications are neither missed nor double-counted. However, the critical issue is that facility staff and local health officials using these data to monitor availability and utilization of emergency obstetric care. Therefore, the need to improve the accuracy of the data should be weighed against the extra (and unrealistic) burden that this would place on staff. One way to resolve this issue is to do a short study to determine whether double counting, for example, is a serious problem. If such a study showed that double counting resulted in a 10% inflation in the number of complicated cases, then either that might be considered an acceptable level of error, or it could be used as a correction factor in other words, the number of major complications might be reduced by 10%. Consistency is critical so that (after the initial period of improving data collecting systems) changes in facility data are due to changes in services rather than fluctuations in data collection methods. However, realistically speaking, we recognize that improvements in the data collection system are likely to have an initial effect on the data. 9. HOW ARE THE UN PROCESS INDICATORS CALCULATED? Indicators 1 and 2: Coverage of EmOC services Both Indicators 1 and 2 deal with the question of population coverage by EmOC services. Indicator 1 deals with the amount of EmOC services available to the population. The minimum acceptable EmOC coverage is one comprehensive EmOC facility, and four basic EmOC facilities, per 500,000 people. To determine the population size in a given area (i.e. national, regional, district, catchment area, etc.), the most recent census should be used. If the census is more than ten years old, a population projection may be used for the relevant year and adjusted accordingly. 16

20 The number of EmOC facilities is calculated through direct observation, interview with staff or review of facility records. All six of the Signal Functions must have been performed in the three prior months in order for a facility to qualify as a Basic EmOC facility. For comprehensive EmOC facilities, those six Signal Functions, plus obstetric surgery and blood transfusion, must have been performed over those three months Example: A health project manager intends to determine EmOC status in 25 facilities in a region. During supervision visits in these facilities, she determines that there is one comprehensive EmOC facility, and 3 basic EmOC facilities. In an additional four facilities, four out of the six Signal Functions are performed, and she makes a note of this fact. The population in the region, using the most recent census, is 745,730. The Guidelines use 500,000 population as the denominator in order to set the ratio of facilities to the population. She begins by dividing 745,730 by 500,000. Region s population: 745,730 = 1.49 Denominator: 500,000 She gets the number 1.49, or roughly 1.5. The Guidelines state that the minimum acceptable level is 1 Comprehensive EmOC facility per 500,000 population. So she needs 1.5 times as many Comprehensive EmOC facilities as she has (1 multiplied by 1.5). She notes that, with only one Comprehensive EmOC facility, there might be considerable unmet demand for services, and, in fact, she has observed that this facility is quite crowded. The Guidelines also state that there should be a minimum of 4 Basic EmOC facilities per 500,000 population. She multiplies the minimum acceptable level of 4 by 1.5 for her region, and determines that 6 basic EmOC facilities are required for adequate coverage. But, this region only has 3 basic EmOC facilities, so it needs at least another three. Reviewing her notes, she remembers that there are four facilities that perform most, but not quite all, of the Signal Functions. These can be upgraded without too much additional cost providing the women in the region with the coverage they need in emergency services. Indicator 2 deals with the geographical distribution of EmOC facilities. To see if the facilities are well distributed, simply look at the geographic distribution of your EmOC facilities on a map, and the distribution of the population. You may have met the minimum acceptable level of 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population. But when you look at the facilities on a map, you may find that they are all 17

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